Social Media Holiday

I’m off work on holiday from tomorrow, so I’m not going to blog again until at least mid June.  I’m imposing a social media ban upon myself whilst I go to Cornwall and do ‘Dad’ things, read some books and see good friends with my wife and son.

Thanks to all for the support the blog has recently received, especially as May has been a record month of interest and use.  The Quick Guides seem to be getting used if the blog hits are anything to go by and I’ve had emails to say they were effective in altering outcomes – that’s what this blog is all about.

When I get back, I’m going to start thinking about bringing the blog to life with different types of resources as I try my hand at a podcast and some other stuff that could be used as training or briefing materials.

I hope you all have a great Jubilee Bank Holiday and a relaxing half-term.  I want to leave you a short video to think about; something which caused me to really think.  It is a five-minute speed-lecture, a rapid tour de force, by Liz Kearton entitled “Madness, Reason and Unreason.”  I put it up to get you really thinking – it should do so regardless of whether you end up nodding or shouting!

What do the police think of AMHPs?

Here is a touchy one! – I was directly asked what the police think of AMHPs? The question struck me  as a strange one as there are over 136,000 police officers and thousands of AMHPs – neither is an easily described group of people demonstrating personal or professional conformity!

However, the question got me thinking: I mulled over various things and decided only a blog will suffice as there are many strands to any attempt to answer!  And of course, there’s MY answer which because of my interest in this subject may look a bit different to the more general, distant impression of a frontline police officer who isn’t especially interested in this area of work.  It is undoubtedly impossible to answer the question directly, a synthesis of 136,000 views is unrealistic; even just my experience of different AMHPs is varied – as will be yours of police officers (if you are an AMHP).  These joint experiences will probably probe the heights and depths of admiration and respect; frustration and obfuscation.

We do this stuff to each other where it doesn’t work so well.

Firstly, I’m not sure that all police officers know what an AMHP is – there’s no clue in the title.  I know that some still think of the old ‘Approved Social Worker’ title and perhaps because of the clue ‘Social Worker’ that spoke for itself.  There is certainly less clarity about what the new title actually represents.  Usually, experiences are restricted to two types of situation: s136 MHA detentions and Mental Health Act assessments; either on private premises or in police custody after people have been arrested for offences.

What I thought would be useful to get close to an answer, is to list questions that have been posed in my direction following incidents.  I think the questions where police officers come into contact with AMHPs represent a balance of uncertainty, ignorance, and frustration; enquiry, interest and expedience.

• Haven’t AMHPs got all the powers of constable after ‘sectioning’ someone? – why don’t they ever use them?  This usually alludes to use of force debates.
• If an AMHP knows someone needs to be ‘sectioned’, but there’s no bed available isn’t their job to find one – I know the answer is no, but it is often assumed the AMHP is in overall charge of the bed identification and overcoming the problem if there are any.
• If there’s no bed available for a ‘section’ application to be made and we’re running out of time to legally hold them; how can someone just be left in the cells?
• Why do several AMHPs tell me you can never do a mental health assessment on someone who’s got any alcohol in their system at all, but some AMHPs are prepared to do it as long as someone is not obviously drunk and can engage?
• When they’re sorting out MHA assessments, why don’t we get a full picture of the risk history if the police are being asked to then manage that risk?  We’re sometimes sent in blind of half-prepared.

Two of my own from getting more involved in this work – because I’ve only ever ONCE seen the first point done; I’ve known the lack of answer to the second point be something that has caused police forces to take legal advice and start legal proceedings against NHS organisations where patients are otherwise left illegally in police cells:

• If someone’s in custody for a criminal offence, why do the MHA assessment professionals not think about Part III MHA as an opportunity to balance care that’s needed and public protection.  It’s only ever “Part II or nothing” and this sometimes misses a trick.
• Are AMHPs aware of, and what do they think of, s13 MHA, taken together with s140 MHA and the guidance published (after legal advice) by the former Mental Health Act Commission (now the Care Quality Commission) in their Eighth and Ninth Biennial Reports – paras 4.45 and 2.49 respectively? – what do we think this means? <<< This is a genuine question, not a dig.  It’s ultimately untested in the courts, but I know what I think it means (for whatever that is worth).

The final thing I’d say – those of you how ‘know’ me well will recall this is a recurring theme in my interaction with AMHPs:

• Most AMHPs I’ve met, don’t properly understand s135(1) MHA and this misunderstanding can be a causes of significant operational friction.
• It is frequently misunderstood that an AMHPs delegation of detention and conveyance authority under s6 is not something that can be directed.  It is dependent upon acceptance of that authority.

Penultimately, the Richard Jones Mental Health Act manual contains opinion and views that are at odds with various examples of legal advice to the police service from barristers who specialise in Mental Health law.  I’ll let you decide for yourself what you think that means and I hope this post is seen as an effort to engage a debate. Fire it back!

MY THOUGHTS

I’d like to say this: many AMHPs I’ve known and worked with a very impressive people, and those I now network with on social media are commanding professionals full of knowledge and experience.  They have to balance far longer term implications in their decisions the most police officers and have a confidence about how to do so in circumstances where most of us would want to just err on the side of caution and keep someone detained or locked up.

I’ve known officers ask, “How can they not section him?!” whilst demonstrating a lack of insight into the role, the law and the complexity of turning someone’s chaotic medical and social circumstances into a “YES / NO” decision about detention when operating on occasions with very limited information.  And there’s an over emphasis on these decisions where they were supposedly invaldiated by a later outcome.  There seems little recognition of where these (often brave) decisions worked to the benefit of a vulnerable person and in no small way contribute to their longer term recovery and prosperity.

I would also add that I think AMHPs are often left in a position of some isolation within the broader health monolith that they operate.  Why can’t AMHPs who need to co-ordinate coercive activity call upon trained health professionals to help them coerce where this is low level and consistent with the dignity of managing vulnerable people?  I’ve known AMHPs express regret when they ask for police assistance because they, like the officers concerned, know it’s not necessarily the best way through the woods of delicate situations.  But for the want of other options they have no choice but to ask.

I wondered what the reasons were behind changing the role from a social work monopoly to one that involves other (often very suitable) professionals.  Now that we’re seeing mental health social work being excluded from CMHTs, I am asking myself that question afresh because as I’ve become fascinated by this area, I think that the social work role in particular brings something precious to both community and inpatient care that would be (or will be!) sadly missed as we appear to re-medicalise our approach to mental illness.

What Do All The Sections Mean?! …

It has only just occured to me to write a post like this, but now that it has, it seems one that was obviously needed months ago! … what do the different sections of the Mental Health Act 1983 mean, especially in relation to policing?

Incidentally, if you’re a cop with a SmartPhone why don’t you save this page on your homescreen – start a little folder with MH reference stuff like this and the Quick Guides?  I know some officers have done so and started using it at jobs and showing it to mental health professionals to influence outcomes! <<< Not the original intention of the blog, but if it helps …

Here is a very quick run down, necessarily a snap-shot, so I’m not going to explain all the ins and outs of every section listed – mental health law books are thousands of pages long!  You could argue about detail on this if you really wanted to but instead, I’d encourage you to read Mental Health Law Online, a website and goldmine of resources, if you want something more specific:

• Part I
• Section 1 – the definition of mental disorder: “‘mental disorder’ means any disorder or disability of the mind; and ‘mentally disordered’ shall be construed accordingly”.

• Part II – this is the terminology you will hear AMHPs and MH professionals using:
  
• Section 2 – the power to detain someone believed to be suffering mental disorder for assessment (and treatment).  The order lasts for up to 28 days and cannot be extended or renewed.  It is imposed after application by an AMHP and two DRs one of whom must be “section 12 approved”. <<< You see? … paradoxically, you need this guide just to understand it!?>!  The patient has a right of appeal against detention to a Mental Health Review Tribunal.
• Section 3 – the power to detain someone for treatment of mental disorder.  This order lasts for six months and can be renewed.  It is imposed after application by an AMHP and two DRs one of whom must be “section 12 approved”.  Right of appeal against detention to a Mental Health Review Tribunal.
• Section 4 – the emergency power to detain someone for assessment for up to 72hrs.  This is in effect a s2 detention, but is imposed where an AMHP and only one s12 Doctor believe it is needed and delay for a 2nd doctor is impracticable.  No right of appeal.
• Section 5(2) – a ‘holding power’ for DRs to detain an inpatient in hospital for up to 72hrs for assessment under the Act.  Cannot be used in A&E because the patients there are not (yet) “inpatients”.  Can be used by non-psychiatric doctors on inpatients with psychiatric problems who are on ‘general’ medical wards in a non-psychiatric hospital.
• Section 5(4) – a ‘holding power’ for a nurse of the prescribed class – usually a more senior psychiatric nurse – to detain someone for up to 6hrs: either for consideration by a DR of whether to use their 5(2) holding power; or to arrange an MHA assessment.  Again, this holding power can only be used on patients already admitted.
• Section 6 – the AMHPs authority to detain and convey someone to hospital for admission under the Act.
• Section 12(2) – Various things in the MHA can only be done by or must include a “section 12 approved doctor”.  Such DRs are those “having special experience in the diagnosis or treatment of mental disorder.”
• Section 13 – the AMHPs duty to undertake MHA assessments and make applications for admission.
• Section 17 – the right of hospitals to grant leave as part of rehabilitation and recovery.  Such leave might be very brief when first granted – an hour or so – and it may be supervised by a staff member.  However, as patients near release it may be for a weekend, for several days or longer.  It is a very necessary part of rehabilitation and recovery for patients.
• Section 17A – the right of hospitals to release a patient from detention subject to Supervised Community Treatment (SCT), otherwise known as a Community Treatment Order (CTO).  Excuse the comparison, (but this page is being mainly written for police officers!) – it is effectively like “bail conditions”.  If the conditions are not complied with, a person can be recalled and failure to return makes them ‘AWOL’ under the Act.
• Section 18 – the power to (re-)detain AWOL patients and return them to hospital.  There is NO power of entry in order to do so.  Can only be exercised in a public place or where legal permission to enter a private building or dwelling has been obtained.
• Section 19 – the authority of hospitals to transfer patients between different MH facilities.

• Part III – these are sections relevant to decisions by criminal courts and prisons
  
• Sections 35 & 36 – powers to remand an ‘accused person’ to hospital for assessment / treatment.
• Section 37 – the power of a Crown Court to impose a hospital order upon a person convicted or found responsible for an offence.  This order can be imposed after a full conviction of following a successful defence of insanity; or following conviction for manslaughter on the grounds of diminished responsibility.  The order lasts until such time as the Responsible Clinician believes it needs to be discharged but patients retain a right of appeal (under different rules) to a Mental Health Review Tribunal.
• Section 38 – an interim hospital order: can be imposed on a convicted or responsible person to undertake assessment and treatment as to whether a full hospital order is the right outcome.
• Section 41 – a restriction order, sometimes known as a ’37/41 order’.  Courts can ‘restrict’ an order made under s37 which subsequently prevents the DR from taking decisions to released the patient, transfer the patient to a different (kind of) mental health hospital or to allowing them periods of s17 leave from hospital.  It obliges the DR to have such decisions authorised by the Ministry of Justice Mental Health Unit.  Such restriction orders can only be imposed if the original court was satisfied that the patient posed a “significant risk of harm to the public.”
• Section 42 – anyone detained under a restricted hospital order is never just ‘released’.  They are always released under this section, in what is known as conditional restricted release.  Again, pleased excuse the comparison, but with my police audience in mind, it amounts to being released on licence, again with some potential restrictions or conditions.  If those restrictions or conditions are breached, the Secretary of State for Justice, through the MoJ Mental Health Unit, can issue a warrant for the return of that patient to a named hospital.  They then assume the status of a s37/41 restricted patient.
• Section 47 – a “transfer direction” authorises the moving of a convicted prisoner to a hospital, if they develop a need for mental health treatment whilst serving their sentence.  By virtue of s47(3) MHA, such a patient is then treated in hospital ‘as if’ they had been sentenced to a s37 hospital order by a court.  This is sometimes referred to a ‘Notional s37′ and I have written a specific post about this.
• Section 48 – same power as per s47, but for remand and other prisoners (such as immigration detainees) in contrast to s47 for convicted prisoners.
• Section 49 - a “restricted transfer direction” imposes restrictions upon leave, discharge or transfer without Ministry of Justice permission, as per s41 MHA.  Sometimes, this is known as a ’47/49 order’, but it for our purposes the same as ’37/41 order’.
• Section 50 – is a “remission direction” to remove a s47 MHA patient back to prison if their detention in hospital for mental health treatment is no longer required but their sentence of imprisonment is not yet up.

• Parts IX and X – offences and police powers
• Section 127 – criminal offence of wilful neglect of an inpatient.
• Section 128 – criminal offence of assisting a person to absent themselves without leave from hospital; or harbouring such patients after absenting themselves.
• Section 129 – criminal offence of obstruction of an AMHP
• Section 132 – the rights which must be explained to someone when detained in hospital, including where detained under s135(1) or s136 as a place of safety.
• Section 135 – warrants under the Act for (1) assessments on private premises; and (2) recovering patients who are absent without leave.
• Section 135(6) – legal definition of a place of safety.
• Section 136 – police power to detain someone in immediate need of care or control and remove them to a place of safety.  Power to detain lasts for 72hrs.
• Section 137 – authority to regard someone subject to an application for admission under the Act as being ‘in legal custody’.
• Section 138 – power to recover someone who has absented themselves from detention under s135(1) or s136 and return them to a place of safety.  Power lasts for 72hrs after they went missing or after arrival at the place of safety; whichever is sooner.

This run down is not perfect! – far from it.  I’m happy to tweak if you think it would add value.

Michael./

Policing and Autism – Part 2

<<< This is a continuation of another post – Part 1.

Appropriate Adults

Of course, this links to broader issues about appropriate adults which I worry about.  I think those who are autistic and find themselves arrested are particularly at risk with this next point: appropriate adults are required by PACE for anyone who is mentally disordered or appears to be mentally disordered.  Individuals with Asperger’s Syndrome and high-functioning autism may not necessarily ‘appear’ mentally disordered (whatever that means) and even where a diagnosis is made known, through alert cards or other information, an appropriate adult should be sought.  It is not necessary to further question whether the person appears to ‘need’ an appropriate adult and this is a mistake often made by Doctors in police custody, both FMEs and those in MH assessment teams.  Appropriate adults are provided for those under 17 and those who are or appear mentally disordered: this is whether or not they appear to be in ‘need’ of such support.  I know plenty of street-wise 16yr olds who know the police custody procedures inside out and probably do not, strictly speaking, ‘need’ an appropriate adult but I cannot imagine a custody officer not ensuring one is called.  We need this kind of attitude in relation to all those in police custody who are mentally disordered, especially where autism and Asperger’s is involved.

Custody sergeants should remember when deciding about appropriate adults: we do not care what a doctor thinks about the utility or value of having or not having an appropriate adult.  We care about whether the person is “mentally disordered within the meaning of s1(1) of the Mental Health Act.”  If they are: appropriate adult.  Autism and Asperger’s are within this scope.

This links to something I’ll reserve for a later post: prosecution related decisions for autistic suspects.  I have never known someone who is known to have or is suspected of having autism be ‘sectioned’ under the Mental Health Act after arrest for an offence.  We know from other work I’ve blogged about before, that whether or not someone is ‘sectionable’ is often a determining factor in deciding whether or not to prosecute and I’ve argue before that this is both legally and morally wrong.  We need to be more sophisticated than that and autism is a point where it is even more important because of the potential of a prosecution decision’s impact upon the person and their life.  More on that in June.

ZH v Metropolitan Police Commissioner

This case from March 2012 involved an incident where officers were called to a swimming pool to deal with an autistic teenager who had “fixated” at the water’s edge.  Against the advice of his carers from his school, the swimming pool manager called the police because of apparent breaches of the rules governing who could be ‘poolside.  The police subsequently proceeded to take hold of the young man to move him from the water’s edge and he jumped in.  After he eventually came to the side of the pool, he was pulled from it and then taken to and detained in a police vehicle until arrangements were made for his care to be taken over.

Action was taken against the Metropolitan Police for assault against the young man ‘ZH’ (touching him at the poolside without lawful authority) and for false imprisonment (detaining him in handcuffs in the police van without lawful authority) and on both points, the case was won – a violation of his Article 5 rights and a breach of disability discrimination law.

Reading the case judgement, is actually a very useful way to understand the arguments put forward by ZH’s legal team as to why the whole situation should have been handled differently.  In itself, it is a helpful insight into how to approach this kind of situation where there was no immediate risk and efforts not to tolerate supposed ‘inappropriateness’ of ZH fixating on the water unnecessarily and unlawful escalated the whole incident.

Finally

Notwithstanding my support for specific awareness training and awareness raising of which these blog posts aim to be part, it is probably worth a reminder about the limitations of awareness training from a frontline police officer:

Sometimes, the action taken by the police at an incident, is necessary irrespective of whether anyone involved – victim, witness or suspect – is living with any form of mental, psychological or developmental disorder.  Whether or not officers can recognise a (broadly defined) mental disorder will vary from incident to incident and officer to officer.  We should bear in mind however, sometimes psychiatrists with ten years post-graduate training who have days in which to clerk and assess a patient can miss autism and Asperger’s.  We need to remember that policing, of necessity, is often emergency reaction to unknown factors and whether a police response is capable of being tailored will always be uncertain.

Last year I attended an event to speak where there was also an input on autism and Asperger’s from a police Chief Superintendent whose son is on the autistic spectrum.  Having covered a lot of information he wanted to leave the presentation on a ‘high’ and I am going to shamelessly steal his conclusion, hoping you recognise the power of this story.  Watch this video to learn about Jason McElwain.

Policing and Autism – part 1

Autism is the one sub-category of mental disorder which I believe warrants a special consideration in how the police service approaches its responses to individuals and to incidents.  Argubaly, this is necessary in order to challenge the notion that it is a mental disorder at all.  Debate about that is ongoing an depending upon whether you are talking medical, legally or socially, you may get different answers.

I argue that police officers need specific awareness of autism and Asperger’s – not only in relation to potential recognition of such conditions, although that is difficult even from trained professionals – but also into de-escaltion, the use of force and implications for justice.  This article is necessarily broad-brush and will followed up in future with some specific posts on certain issues, including by guest bloggers who have offered to help.

Firstly, those in our society on the autistic spectrum are the only service users to benefit from specific legislation – the Autism Act 2009 which gives rise to specific statutory guidance.  Secondly, autism and Asperger’s can present in exceptionally low-profile ways, especially low profile to police officers.  Only when exposure to social situations has brought about an adverse reaction can it become obvious that a police officer is dealing with someone who may need to be considered as mentally disordered or “on the spectrum”.  Thirdly, from time I have spent listening to speakers in training events and conference which have included professionals, academics and parents or carers, it is clear that achieving a diagnosis at all can be extremely difficult and that access to appropriate services can be even harder once a diagnosis is obtained.  Fourthly, given debates about whether it is even valid to consider autism and Asperger’s as a mental disorder, it occupies a position of ongoing ambiguity in terms of how it is classified and this links to all sorts of other debates about legalities and implications.

If you don’t know very much about Autism and Asperger’s Syndrome, then you should consider reading more about what they actually are on the National Autistic Society website.  It is replete with information and resources and there is a specific guide for Criminal Justice professionals.  It is also fair to say, that health and mental health professionals have been accused of being under-aware of the spectrum in their delivery of mainstream mental health services and that they should be seeking to do more and know more about it.

Police officers would do well to bear in mind the following (all too brief) advice whenever they know or suspect they are interacting with someone with autism; but also, do look on the above websites for far more:

• Communication must be clear – avoid jargon, acronyms and metaphors; your speech may be taken very literally so bear this in mind.
• Patience is a virtue – rushing, issuing ultimata and orders can heighten tensions; force, as ever, is the last resort, only where absolutely needed.
• Take account of familiarity / routine - taking advice from or including people familiar with a person, their routine and their normality can reap huge benefits and avoid inadvertently escalating situations.

The Invisible Disability

I once heard a parent speak of “The invisible disability” of her son’s autism at an event where I was asked to speak about policing in relation to autism and mental illness.  Her son’s diagnosis had been achieved only after he was arrested by their local police and after they had contacted her following arrival at the police station (he was 16 at the time).  Discussions in custody led to the young lad being ‘diverted’ without being charged and the subsequent health sign-posting led to his diagnosis.  Interestingly, she made it clear that it was the police custody sergeant suggesting that he wondered whether autism was an issue, which lead to that being considered.  The custody sergeant’s daughter was autistic.  The FME who had already examined him upon arrival at the station, had not raised such concerns.  It lead to a second medical examination to achieve the required sign-posting and this led to diagnosis.  The main thrust of her input, concerned a lack of services to support her family after battling to even get that far.

Other stories are not so positive:  I remember a few years ago hearing of a case where an adult man with a diagnosis had presented his “Autism Alert Card” to a custody officer after arrest.  He had been arrested after being followed by a police car and required to stop – the UK police have a legal authority to stop any driver without what the Americans would call, “probable cause”.  Quite simply, the young lad was driving a large, expensive vehicle which would cause the “are you really insured to drive that?” question.  Because the young man knew he hadn’t committed any kind of offence at the point where the blue lights went on – he hadn’t, it was a routine stop-check – he chose not to stop because he knew he’d done nothing wrong.

Of course, failing to stop for a police officer is an offence which meant the police started the relevant processes to get him to stop.  By the time this was achieved there was sea of blue flashing lights and police officers which the man struggled to handle and comprehend – he was arrested for a minor public order offence and taken to custody.  The police promptly ignored his “Autism Alert Card” which indicated who should be contacted for advice and so they failed to join the dots between the card itself and the legal requirement to ensure an appropriate adult who would have then supported him in custody and presumably given the police a lot of information.  Autism is a mental disorder for the purposes of the Police and Criminal Evidence Act 1984 and the Mental Health Act 1983.

This post is continued. >>> Part 2.

Monthly Update – The Use of Force

The use of force by the police in relation to incidents involving mental disorder is the thing that has occupied by thoughts this month. Always controversial, often very necessary, but occasionally capable of question in terms of how the situation was brought about that it fell to the police to use force; or how situations escalated to such a degree that the police believed the use of a high level intervention was necessary.

We heard in early May that Humberside Police used a taser during an incident where dementia patient Peter Roberts was ‘sectioned’ under the Mental Health Act.  My post on that incident generated a welcome debate on twitter.  Shortly after this, I wrote about an incident on which I’d been asked to give a view in support of officers who were inclined to resist requests that they should be the first professionals to lay hands on an elderly dementia patient who was resisting admission to hospital under the Act – verbally and passively.

The fallout form the first incident should be causing us to ask questions about how routine the second type of incident actually is; and why do some NHS areas often have no coercive capacity other than the police?  Important to re-state: I’m referring to low level, passive and verbal resistance – no-one is exepecting NHS staff to put themselves at risk of assault or serious harm, but unless such risks are likely, the police may well legally be obliged to consider resistence or refusal in some circumstances.  More to be done here in partnerships.

Of course the use of force by mental health or social care professionals is controversial, not just because all use of force needs to be very carefully judged but also because when engaged in undertaking such functions, it is quite possible that the person using force, despite best efforts, planning and proper training, may find themselves assaulted during the resistance of the person being moved, detained or restrained.  I’m aware that over two-thirds of assaults on NHS staff are against mental health professionals; I am aware that many mental health nurses will say they’ve only ever been assaulted by ‘older adults’.  This makes the discussion about our joint approach and training / deployment of properly trained NHS staff more important, not less.

My own view, is that Parliament legislated in that way that it did – to allow force to be used in realising the effects of the Mental Health Act – with a range of circumstances in mind.  For example, it reserved certain powers under the Act to the police – execution of warrants under s135, detention of people in immediate need of care or control under s136.  The obvious question to ask is why powers under s18 MHA (recovery of AWOL patients) were not reserved exclusively to the police; why the powers of detention under s6 are reserved to an AMHP, albeit it with the ability to delegate those powers.  We should then ask what the practical implications are of AMHPs being unable to direct or instruct other professionals (like ambulance or police) to detain and convey under s6 on their behalf.

I can’t get my head past this:  Parliament’s intentions, or the effect of their legislation, is that some MHA patients should sometimes be detained and conveyed using health and social care professionals only; other situations should involve the police being in the background of efforts in case things escalate suddenly; and the police should be the lead agency where the patient can fairly described as ‘dangerous’ or ‘violent’.  NB – ‘dangerous’ and ‘violent’ do not simply mean ‘resistant’ or ‘verbally aggressive’.  Perhaps those later epithets indicate where officers should be in the background, in support?  We need to ask ourselves in a far more meaningful and sophisticated way, what the words “least restrictive” means.

For me, it means uniformed police officers are never the first thought when force should be used.

I repeat my model for indicating where the police should be involved in the execution of Mental Health Act related processes:  RAVE risks.  As far as I am aware, this is the first attempt to put together a framework to help professionals on all sides understand situations in which the police should be involved, because any suggestion of it causing stigma or the appearance of ‘criminalisation’ (whatever that means) can be explained against the risks to all of the police not being involved.

Autism awareness and the Use of Force

At the end of March, the High Court ruled in a civil action brought against the Metropolitan Police, involving a case where officers restrained an autistic teenager at a swimming pool.  The case of ZH v Commissioner of Police for the Metropolis provoked an understandable outcry, not only because of the use of force being used, but obviously because the use of force was ruled unlawful in this instance, therefore representing an assault and a false imprisonment.

Again, it brings into focus the specific issue of Autism about which I will try to blog during June if time allows.  I have heard many times that officers not only need “mental health awareness” but they also need particular awareness of sub-categories of mental disorder:  learning disabilities, Alzheimer’s / dementia; autism, personality disorder, etc..  They are more.  Having attended many conferences, events and training sessions on these issues over the years, I offer this view: of course, officers need training that includes reference to and explanation of these sub-categories and their differences.  However they only need specific awareness training of particular sub-categories where the training is able to outline why a necessarily different response to individuals is required.  For me, the only example of this is Autism.  And this may be because it is highly contested whether Autism should be viewed as a mental disorder at all.

Whatever we think the need for officers to reflect on their communications; de-escalation and the use of force and many other aspects, it is often the case that these things are generic across sub-categories of disorder.  incidentally, I’d got further – whenever I hear charities talking about how to communicate well with service users where they are in crisis or at risk, I always think, “That’s how we should communicate with everyone all of the time, anyway!”  Avoid jargon, be clear, don’t patronise, don’t deny their emotions as it may escalate situations, etc.. However, in the particular case of police responses to members of the public on the Autistic spectrum, we need to be aware that things are different.  This is perhaps why Autism is the only sub-category of mental disorder with its own legislation: the Autism Act 2009.

De-escalation techniques

Contrary to popular belief, “de-escalation” techniques are very much a part of officer safety training: it’s just that we don’t call them that.  Officers are only permitted by law, to use force after trying and failing to use “tactical communications” and “officer responses” to de-escalate, or having reach a conclusion that force is required immediately to ensure safety and prevent crime.  In other words, if you can talk someone down, you have to or you have to try.  You can only move to various levels of force once satisfied that it is “Proportionate, Legal, Appropriate and Necessary” to do so: you must PLAN, your use of force.

This will continue to be controversial and force will again be used because the administration of the Mental Health Act involves the coercion of fellow subjects; whether by NHS staff and / or the police.  That’s why we must continue to think and talk about how best to do it, very much with safety AND dignity in mind.

Turgid Buffoonery

Discussion about mental health and policing often turn to the law.  Not only in terms of who can do what, but also in terms of how or when it should be done.  Some of these debates are delicious because in many respects the law is quite vague and many people COULD do certain things, but who SHOULD do them can be a cause of tensions and reasonably differing opinions. Sometimes, different opinions can be less reasonable.

I have a theory that in an attempt by professionals in each agency to cause the others to do certain things or to do certain things better, differently or faster; we’ve entered into myth-making on a near industrial scale and that this is represented in certain “legal” discussions.

As a police officer trying to get my head around mental health law some years ago – an effort I still make when I find myself uncertain – I found it very different in nature to law that I had studied in promotion exams for the police.  Far more inclined to be vague.

It is interesting that the syllabus for the legal examinations to sergeant and inspector do not include examination of ss18 and / or 135-8 of the Mental Health Act 1983 – these are the main sections for the police.  There are other sections of interest to those of us who are more involved in policy work around this, such as 6, 13 and 140 and all of Part III MHA.  Of course there’s then the Code of Practice to the Act: all police supervisors should read chapters 10,11 and 21, 22; and chapter 4 for those of us a touch more interested.

I find the Code of Practice itself interesting – the police have loads of these things for different laws and I’ve previously blogged about the difference in some cultural attitudes between the police and the NHS towards them.  I was interested last week for example, to be told of an NHS area who WANTED a mental health patient detained in the cells because they were under the influence of alcohol: “we cannot assess someone whilst they’re under the influence because it breaches the Code of Practice and we ignore this at our peril”. Well, it actually doesn’t – this is more mission creep: it is advised against except in some very specific circumstances.  However, my main concern was that this remark came from professionals seeking the removal of a person to the cells when a perfectly available NHS PoS was sitting there, empty.  They were worrying about hypothetical future patients, yet to be detained when someone was in need of the place – if we detain someone else in half an hour, we’ll cross that bridge at that time.  In the meanwhile, you want the police station used as an automatic second choice when you’re not unable but simply unwilling to let the NHS PoS be used?!  Please read 10.22 to the Code of Practice to the Mental Health Act 1983 and then read R (Munjaz) v Ashworth Hospital Authority (2005).

So, after a day at work as the duty inspector where I was exposed to some nonsense about missing patients, MHA assessments from NHS and to myths about the “capacity” of offenders by police officers, I just wanted to quickly list some other rubbish that I’ve heard in my time.  I hope to provide balance by being equally dismissive and disparaging of nonsense heard from each side.  Many of these things are urban myths and have become ingrained in some areas’ operating practices.

I am only including things in this list if I have reached a point of being utterly bored of hearing them owing to their frequency:

• The police cannot arrest under s136 MHA if the person is in A&E
• To decide whether or not to prosecute a mental health inpatient for an offence, the police need a statement of evidence from a psychiatrist affirming the patient’s “capacity”.
• Only the police can keep someone detained against their will in a Place of Safety, after being removed there under s135(1) or s136.
• Only the police can use physical force to restrain a patient in a community MHA assessment, in order to compel that person to hospital once ‘sectioned’.
• It is always the role of the police to recover AWOL patients.
• If the police are in a private dwelling dealing with a mental health crisis, they can use the Mental Capacity Act to remove the person to A&E or a place of safety.
• Victims of crime with mental illness are inherently unreliable at court.
• Once you’ve detained a patient who is AWOL from hospital, you can keep them in a police cell if the hospital to which they should be returned does not have a bed.
• A&E is NOT a place of safety.
• An AMHP cannot use force on a person who they’ve just ‘sectioned’ to move them into an ambulance.
• Paramedics cannot use force on a person that has been sectioned by an AMHP [who has properly delegated authority under s6.]
• An AMHP can order or instruct the police or ambulance service to detain and convey under s6 MHA, someone for whose admission to hospital has been applied.
• If we don’t have a bed into which the admit someone who needs ‘sectioning’ then we don’t have a bed and that’s the end of it.
• Violent patients detained under s136 MHA should always be detained in the cells.
• A person who is detained under the MHA in hospital can’t be arrested or prosecuted.
• You cannot get a s135(1) warrant for an MHA assessment if you already know you can get access to the premises.
• The police can neither apply for nor execute a s135(2) warrant on their own.
• You cannot arrest and remove a s37/41 hospital order patient from a secure unit after they have committed a serious offence.
• You can’t stop psychiatric patients leaving a hospital ward and going AWOL if they want to.
• You cannot arrest an inpatient for an offence, unless the RC in charge gives permission.
• There is no point, legally, in prosecuting a s3 patient for violence on wards because they’ll end up back in the same place getting the same care from the same professionals.

I might add to this list if more comes to mind – feel free to add your own, below!  But this stuff is just turgid buffoonery – some stuff is just “wrong”.  Which other way do we need to describe “wrong”?! … and we all do it to each other.

Whilst I Was In Bed …

<<< If there’s one thing from which I derive very real satisfaction, having blogged away now for six months, then it is emails from frontline officers saying how the blog material has come in useful in operational reality.  To get such a story as this one where it is clear a better patient outcome has been achieved for someone whilst I was lying in bed after NIGHTS is gold dust.  This feedback comes from Twitter’s @NathanConstable, a blogging / tweeting frontline police inspector who is worth a follow and does good blogs on policing issues. >>>

Your site has AGAIN proved invaluable today as I have quoted Paragraph 10.22 of the MHA Codes of Practice to a ward manager.

The Circumstances

A man was seen yesterday by a support worker, at home, who felt he needed an MHA assessment but he left the house before it could be jacked up and he was reported missing as she had concerns for him. He was located several hours later by police who detained him under 136.

He was conveyed to the PoS but they didn’t want him for a variety of reasons. Eventually the night Inspector went down there himself and told them he would be staying there whether they liked it or not.

As I came on at 0700hrs this morning and just three minutes into briefing, we had a call from the hospital saying that a patient was kicking off, that he had assaulted three members of staff and five of them were restraining him. I did not realise at this point that it was the same male.

My view at this stage was that this is something they need to be handling themselves with their appropriately trained staff.  However, when it became apparent that he was pre-section and still detained only on 136 I had to revisit that and I sent a unit with specific instructions NOT to remove him from the hospital unless it was absolutely necessary.  By this time the patient (still not assessed) had been moved into a secure room by the hospital staff and was no threat to anyone any more.

Apart from their initial unhappiness about our lack of attendance they were then extremely unhappy when the officers refused to take him away. This led to the Ward Manager calling me to discuss.

His view was that the hospital was not an appropriate place for him, they “couldn’t handle” him and he needed to be detained in a cell.  My response to that was that a police cell was not appropriate, the HAD handled him and he was now detained in an appropriate place of safety.

Not content with this the ward manager informed me that the room being used was not THE PoS. To which I quoted 10.22 and said he had effectively improvised one.

He persisted that by using the room it was denying its use to a hypothetical service user who might need it later.  He even went as far as to say that it would be on my head if a 80-year-old dementia sufferer ended up in police cells because they couldn’t use the room.

My answer to that was – why are you worrying about hypothetical “what ifs” rather than dealing with the service user you have in front of you?  If an 80yr-old dementia sufferer turned up I would improvise my own PoS and take her home rather than convey her to a cell.

The debate continued with him accusing me of thinking it was alright to assault staff.  I said that is not the case at all – his medical and clinical status is not yet ascertained so I don’t know whether his actions are criminal or not yet – if they are we will deal with them but that is not the priority right now – his assessment is.

Then he moved onto the fact that the patient was unlikely to be sectioned as he had been examined before. I asked him three questions.

Question - “What happens if he is Sectioned?”

Answer – “He stays in hospital.”

Question - “What happens if he isn’t?”

Answer – “He is released.”

Question - “What happens if he is so violent that the AMHPs cannot conduct the assessment or make valid assessment.”  …  it took him a while to admit that in that eventuality he would be detained for further assessment to which I said, “Two out of three of those scenarios involve him remaining in hospital and the other see’s him walking out. Where does a police cell come into this?”

I then explained that it wasn’t a question of having police officers involved – I was quite happy to supply a double crewed unit to ensure no crime was committed before or during the assessment. For me it was a question of WHERE this would take place and I would not, under any circumstances, take him to the police station now he was secured in a safe and secure room.

The ward manager reluctantly accepted this – which suggests to me that I was right.

The inevitable, “I will be making representations about this” came out but the question is – was I right? I think I was. I will accept that had I known he was pre-section in the first place that might have changed my initial “how quickly we got there” approach but not the eventual outcome.

The fact that seven hours later we are still there is something I have to accept. Their other problem was a refusal to change their schedule for the day.  Common sense dictates that they bump this guy to the top of the queue – and assess him – we know where we all are and the room is either utilised fully or he is released thereby freeing it up. Problem solved. Unfortunately they seem to have had a series of unavoidable meetings which is delaying the whole process.  What a surprise.

The outcome was, he’s been detained under s2 MHA and admitted.  I doubt I have heard the last of this one!

My Comments

Was this duty inspector right?  Feel free to add your own comments to this post.  For me, certainly.

He has provided a response which ensured ongoing security to prevent further assaults and whether or not the NIGHT shift should or could have left resources at the PoS to prevent assaults from occurring in the first place, is not clear in terms of the risk background.  But that is not an issue for this inspector.

It is quite right to point out, that PoS solutions can be improvised notwithstanding what a PoS protocol stipulates the designated places to be and para 10.22 obliges the police AND the NHS to think of the alternatives.  This may not be “textbook”: it might not be what all NHS staff think is the right thing – but we’ve all got personal views on this stuff, haven’t we?  It was lawful, reasonable and ethical and it probably caused a faster assessment of MH need in a more appropriate place than if the police had just got back in their box and done as they were told.  Of course, had they done so, I’ve got various medical and legal situations playing out in my head which would have rendered acquiescence questionable.

Let’s not forget the criteria for use of a police station is “unmanageably high risk” and the officer points out, they managed it and then were supported by the police thereafter.  Let’s also remember: the Royal College of Psychiatrists Standards on s136 indicate that people detained should be taken to and left with NHS services “even where they are disturbed” (p8).  That ongoing police support was provided may be considered ‘extra’ to support a service that doesn’t function as agreed by relevant national agencies.  We should also remember that the recommendations of the Rocky Bennet Inquiry indicated that where psychaitric patients are in need of ongoing restraint, they should be detained a place with access to a Doctor and defibrilator.  That include no police station that I’m aware of.

It is for that reason that I smiled when I read the paragraph above “You’ve effectively improvised one.”  Can we doubt the commitment to investigate the assaults against staff or ensure they are not repeated?  Not really.  Removing the man to a police cell doesn’t un-assault the staff; nor does it ensure fast assessment of need.  Providing two cops to remain at the unit keeps the situation from re-escalating and represents a recognition from the police that the risks have raised and that whatever the rights and wrongs of the way the service is commissioned or the fact that staff would potentially prefer to operate outside the law and national guidance, the police have done the right thing in my humble view.

Section 136 and the FME

The Force Medical Examiner, or Forensic Medical Examiner, is the doctor who comes into police custody suites to undertake various medical functions.  The terminology for these professionals has changed over the years and is now officially the “Approved Healthcare Professional” which is helpfully confusing when I want to discuss AHPs in the context of functions they must undertake with AMHPs (Approved Mental Health Professionals under the Mental Health Act)!

For that reason, I’m going to persist with the outdated term, “FME”!

When I joined the police, the FMEs were a load of local doctors, mostly GPs, who were on a rota.  My station and two others had four of them and they were in each subsequent 7 day period “first choice” then “fourth choice” then “third choice” etc..  Many of them earned more from being an FME than they did from being a GP because they worked about 24/7 for a week, then had two weeks ‘off’ (because 3rd and 4th were rarely called) and then a week of being called ‘occasionally’.

Presumably because of cost and some debate about skills, training and clinical governance, somewhere around 2002, my force contracted a private provider to undertake all medical functions in the custody office and elsewhere, introducing nurses for certain functions rather than doctors.

The FME has an interesting role with regards to s136 and it varies across the country.  Legally, once someone has been detained by the police and removed to any place of safety, they must be seen by a “Registered Medical Practitioner” and an AMHP.  The RMP needs to be a doctor and there is no specific requirement that they be “s12 approved“.  Section 12 approval relates to doctors who are declared to have “special experience in the diagnosis or treatment of mental disorder”.  Many functions for doctors under the Mental Health Act 1983 require a “s12 doctor” but s136 MHA is not one of them.  In fact, many FMEs in fact ARE “section 12 approved”.

The Mental Health Act Code of Practice states that the RMP should ideally be s12 approved, but stops short of mandating it.

Force Medical Examiners being used outside police custody

Sometimes, local s136 policies specify that even where a person is removed to an NHS place of safety, the FME should still be involved in the s136 assessment.  There are a few problems with this which then emerge in reality.

Firstly, some force contracts with their medical provider, do not cover it and therefore some FMEs are told by their contracted employer not to undertake such functions.  Assessment under s136 MHA is a statutory responsibility for the NHS and therefore, the NHS should ensure that the commissioning of PoS services ensures the availability of whatever kind of DR they believe is the most appropriate.  This has caused tensions and problems, because it sometimes only became known that FMEs were involved, once contracted medical companies were overseeing FME schemes.

It turns out, RMPs can claim a statutory fee for s136 and MHA assessments, so plenty of FMEs were happy to do it.  But then some NHS areas started trying to suggest that as the doctor “worked for the police”, the police should pay that bill.  Err, no.

I have recently been looking for a reference which I’m sure I once read in the Code of Practice to the MHA, which indicated that PCTs should not rely for the delivery of services upon third-party organisations that are not directly commissioned.  Contracted police FME services are one such example, where reliance by the NHS on a service they did not commission and do not control, can lead to operational problems.  PCTs must ensure they have answer to “how s136 gets done.”

I suspect some of this may change in the future when the NHS takes overall commissioning responsibility for healthcare in police custody, at the point of writing this, it remains true.

Force Medical Examiners in police custody

FMEs have been used in various ways for s136 assessments in the cells.  In some forces, the local authority WANT the FME to get involved in a ‘screening assessment’ before the AMHP is notified, ostensibly so that the FME gets rid of any s136 detention which is obviously inappropriate.  In other areas, the local authority specific DO NOT want the FME to make any decisions whatsoever around s136 MHA, because they want to bring their own RMP, usually off the “section 12 approved” rota.

Each of these scenarios poses a different, interesting question: if the FME is screening people out, on what basis are they doing so?  I ask because I know that some doctors think the question to ask of s136 patients is whether they are ‘sectionable’ under the Mental Health Act.  In fact, the purpose of s136 assessment is not (just) to establish whether the person is ‘sectionable’, but “whether they are mentally disorder for the purposes of the Mental Health Act” and to identify subsequently necessary care pathways.  These could be inpatient OR outpatient pathways.

The second quandary is interesting: if the FME gets to police custody with a view to doing “FME things” and staying ‘out’ of the s136 process – police want FMEs to confirm fitness to be detained in the police cells, levels of safety observations which will be undertaken whilst the person is there, helping with decisions around whether they need removal to A&E for any purpose perhaps after a physical examination – what then happens if the FME who is an RMP thinks the person is “not mentally disordered within the meaning of the act”?  The Codes of Practice to the MHA and to the Police and Criminal Evidence Act 1984 both state that if an RMP believes the person is “not mentally disordered” etc., then the person should be released and s136 comes to an end.  To detain beyond that point would be illegal; a false imprisonment by the police.

However, in more than one joint operating protocol that I have read, the policy states that no-one detained under s136 MHA in a place of safety will be released until they have been seen by both a doctor AND an AMHP.  Which could amount to a false imprisonment, in some cases.

I also know of local protocols where the local authority want the FME totally removed for the s136 process, even where they are in police cells.  This usually stems from a history of incidents where the local authority found that FME decisions were way off mark, leading to the unnecessary release of people who were quite unwell.  But of course, the custody sergeant is obliged to call an FME for reasons above, that are nothing to do with s136.  Safer Detention guidelines and PACE require it.

I understand the importance of the AMHP role in s136 assessments.  Not only do AMHPs make arrangements for full MHA assessment if the “s136 assessment” indicates compulsory admission to hospital may be needed.  Also, even where admission may not be necessary but where the person detained is suffering from mental disorder within the meaning of the Act, the AMHPs role is to ensure the relevant community follow-up.  This may take one of many forms, including referral to the patient’s own GP, or community based mental health services.

So a tension in police custody can emerge, depending on how local s136 protocols are drafted:  the custody officer is responsible for managing this tension and my advice is this:

• Notify the FME for assessment as soon as practicable after ‘detention authorised’.
• Notify the AMHP as soon as practicable after ‘detention authorised’ of the s136 detention in your cells and give the FMEs estimate time of arrival.  The AMHP can then choose whether or not to be present at the same time, as preferred by the CoP MHA.
• If the FME arrives first and assesses the person to any degree, the question to ask is, “Is this person mentally disordered within the meaning of the MHA?”
• If yes – continue to detain for the AMHP.
• If no – section s136 has been brought to an end by virtue of this assessment.  Unless you think for good reason that the Doctor is way-off in their conclusion, in which case contact your on-call senior FME (most forces have this) and notify the AMHP.

Footnote: “Not mentally disordered” after removal to A&E

The references highlighted above about RMPs indicating that someone is not mentally disordered has one further consequence that is worthy of mention in this context, although it is not about FMEs.  Where a person has been removed to A&E – presumably because of additional RED FLAG injury / illness which makes this necessary – it could be that an A&E doctor states that a person is “not mentally disordered …” etc..  Where this occurs, it again raises the question of whether s136 should be brought to an end, irrespective of whether the AMHP has arrived or been notified of the detention and undertake an interview.

After much discussion on this point it comes back to the Code of Practice to the MHA (para 10.33): “If the doctor sees the person first and concludes that they have a mental disorder and that, while compulsory admission to hospital is not necessary, they may still need treatment or care (whether in or out of hospital), the person should still be seen by an AMHP.”

Policing, Mental Health and the Academic Gap

I was delighted to be asked by Dr Jez Phillips from the University of Chester to write a post for his blog.  It is a goldmine of articles and resources in forensic psychology and his fear of crime research project is detailed on there for which he needs support especially from tweeting police officers.  I’d encourage you to check out his research and his resources and to follow him on Twitter (@DrJezPhillips).

My contribution to his blog was entitled “Policing, Mental Health and the Academic Gap“.

__________________________________________________________________

I am delighted to be asked by Jez Phillips to write a guest post for his blog – what an honour.  It struck me that if a serving police officer is to write for an academic’s blog, one should point towards the subject of academic research and operational policing.  Apart from anything else, this is a subject dear to my own heart having taken a keen interest in academic development throughtout my career.  Also, my work on policing and mental health within the service has led me to ask so many questions and often one finds there is no answer at all.  I’ve said many times: there’s a lifetime of research here for someone and I occasionally I wish it were me.

I want to cover just three substantive points:

• Policing and mental health
• Policing and academia
• Research gaps in the real world

Policing and Mental Health

Anyone who reads my blog will know that policing and mental health is a vast subject.  Not only in terms of it’s potential complexity, but also it’s breadth. It gets into the most important social and public debates that we have, in some of the most challenging circumstances: public protection, the protection of the state – or lapses of both.  We touch on life-threatening medical emergency, deaths in custody; the diversion or prosecution of offenders, vulnerabilities of every kind as well as emotive issues of unpredictable violence.

Some research estimates that mental health issues affect around 15% of all policing: either in connection with victims, witnesses, or suspects; or because of incidents that involve no criminal offences at all.  I think this is in many respects an under-estimation.  For example, I know that police officers often ‘spot’ around 15% of people coming through police custody suits and for one reason or another, ask the ‘mental health questions’.  However, were the names, addresses and dates of birth to be shared with the local mental health provider, what would we find?

How many are known to the local mental health trust?  Well, there was a localised initiative in Sussex which found that 50% – yes, HALF – of all people arrested were either currently known by, previously known by or needed to be known by their secondary care mental health provider.  As secondary care deals with severe and enduring mental illness, we should remember that around 17% of NHS patients needing mental health care are supported in primary care, by their GP.

We don’t even know the size of the problem.

Policing and mental illness can also be about profound episodes of public confidence in policing.  Death in custody inquiries are disproportionately populated by contact between police officers and service users whilst at their most vulnerable; and often their most challenging involving substance (ab)use.  I have written more blog posts on the subject of s136 Mental Health Act 1983 and Places of Safety, then on any other subject within my area.

At least one contact death inquiry per year is focussed upon police detention under s136 and yet it remains the case that most people arrested by the police under this provision are removed to police stations in stead of health facilities.  This happens against a backdrop of so much guidance and so many guidelines that police stations are not appropriate for detaining mentally ill people in need of nothing more than assessment, treatment and care.

Policing and Academia

Policing in many regards is the last public sector vocation-profession to tie itself up with academia.  Whereas years ago teachers, nurses and social workers were taught in vocational training institutions with a good spread of placements and ‘on the job training’, this has now given way to university education, albeit it still interspersed with vocational placement within the context of that degree.  We can see that policing is moving towards this, and not before time:

There are various university courses now on ‘policing’, at the Universities of Staffordshire, Wolverhampton and Teeside, amongst others.  It would be remiss of me not to highlight the BSc (Hons) degree in Policing at Wolverhampton because of its strategic liaison with West Midlands Police – it is a requirement of the degree that students are accepted as special constables and serve a certain numbers of hours of voluntary service during their three-year course.  Furthermore, there is a second year module on ‘mental health’ delivered by the Nursing school of the university, a recognition of the link between the two subjects that I have not seen in any other institution.  It is my privilege to have delivered a guest lecture on this course for the last few years.

Of course, the University of Portsmouth entered the higher education market for all manner of criminal justice professionals several years ago, through distance learning as well as campus based provision.  I know that many police officers have seen this and other higher education provision as the key to professional advancement, but we remain a distance from police training being university based.

Increasing links with academia are forging this path: the Universities Police Sciences Institute is a joint venture between the universities of Cardiff and Glamorgan and South Wales Police.  UPSI provides research, training accreditation and closer ties between the frontline and peer-reviewed research of national and international recognition.

The most interesting link between academia and policing is the Violence Research Group at Cardiff University.  The work of Professor Jonathon SHEPHERD is truly inspirational: his analogy of how research and professional practice in medicine is a world away from that in policing, but how the latter needs to m’ve towards the former, is astounding.  I can see the benefits of this and hope within my career, we’ll have stepped towards that kind of vision.

Research Gaps in the Real World

Policing will play an increasingly important part in the provision of mental health care in the future, in my view.  Linda TEPLIN wrote in the early 1990s that police officers were “street corner psychiatrists” and if anything, this is truer now than ever.  One theory is that as the ‘de-institutionalisation’ of mental health care gave way to ‘Care in the Community’, policing increasingly filled a gap in crisis care and crisis support.  Initially, this brought law enforcement techniques and practice into crisis management and there were predictable consequences.

In most countries there has been more than one controversial use of lethal force in relation to someone who is mentally ill.  Andrew Kernan in the UK is just one of several such controversial deaths.  Following the fatal shooting in Memphis in 1988 of a service user, US police departments started to adopt “Crisis Intervention Training”.  This represented an alliance between the police and local mental health providers and universities to give officers accredited training to deal with mental health service users using techniques and approaches likely to reduce the need for the use of force and to increase ‘diversionary’ approaches to avoid arrest / prosecution.  I’m looking to introduce a similar approach to this in the UK and will be trialling something later in the year.

Meanwhile, there are many other academic questions and areas of research activity that need tackling.  We need to know more of the “what, where, who, when and how” of policing and mental health.  Basic research needs doing to establish “what works” as so much about criminal justice approaches to mental health remain based upon assumption or upon research undertaken by interest groups such as mental health charities.  There is a dearth of peer-reviewed, high quality academic research on this topic and in my own view as a practitioner with a quasi-academic interest, I’d like to see this plugged by non-political (small ‘p’) research in a neglected area of policing and criminology research.

So – does diversion work?  I’m still not convinced of the reports I’ve read from various charities that the legal frameworks of the country that we have fully specified what we’re trying to do in the ‘diversion debate’.  I’m still not convinced we know what ‘diversion’ is or the legal frameworks within which it actually operates.  Far to much assumption, stigma and unreality.  Accordingly, how do you begin to assess whether it ‘works’?  Whatever that means …

So – are police shootings properly understood?  I’m not convinced that we understand sufficiently the dynamics that are at play when the police use potentially lethal force against people with mental health problems, some of whom we know are putting themselves in harm’s way with a raised risk of being subjected to force.

So – how does the justice system react to victims with mental health problems?  I’m not convinced that we have a criminal justice settlement for victims and witnesses.  In our adversarial model of justice, focus upon what makes a ‘good’ witness, discriminates against those with mental health problems and we know from the case of R (B) v DPP (2009) that victims do not always get a fair deal in our justice system.

So – how do we find ourselves unable to guarantee effective crisis care?  I’m not convinced that legal cases which have highlighted shortcomings in our social response – R (B) v DPP (2009; MS v UK (2012) – are absorbed as ‘lessons learned’ and taken forward into the development of services.

I’m nearing my word limit, which is the only reason I have stopped asking questions.  There are many more to be asked.  This issue will not abate during the coming years: we know psychiatric services are withdrawing further from the provision of inpatient, outpatient and crisis mental health care and we know that internationally this means the police service will be sucked into the vacuum.  It is therefore even more important that we understand the size of the problem and ask ourselves, “What works?” on the basis of understanding what is needed.